Abstract

Objective A rare complication of neuroendovascular procedures is acute thromboembolism. In the setting of intraprocedural or periprocedural embolism, thrombolytics present a potentially useful therapeutic strategy. A series of patients in whom eptifibatide (a platelet glycoprotein IIb/IIIa receptor inhibitor) was used in the treatment of iatrogenic thromboembolic events occurring during elective neuroendovascular procedures is described.

Methods Consecutive cases between May 2009 and July 2011 in which eptifibatide was administered were identified and individually reviewed for inclusion in this study (n=12). All study patients received a uniform, weight based bolus dose of 180 μg/kg of eptifibatide administered either intra-arterially through the guide catheter or intravenously. Eptifibatide infusion (2 μg/kg/min) for 24 h after bolus dose administration was continued at the discretion of the surgeon. Procedural details are described and illustrative cases presented.

Results Three major categories of thromboembolic events were isolated in the course of review of study cases: acute focal neurological decline and no radiographic findings of flow limitation (eight patients), radiographic findings with or without symptoms (two patients) and persistent particulate debris during flow reversal as part of a carotid revascularization procedure (two patients). Following eptifibatide administration, no patient experienced hemorrhagic complications, and neurologic improvement to baseline level was noted in 10 of 12 patients.

Conclusion Eptifibatide may be an effective therapeutic strategy in the event of thromboembolism during elective neuroendovascular procedures.

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Footnotes

Competing interests LNH receives grant/research support from Toshiba; serves as a consultant to Abbott, Boston Scientific*, Cordis, Micrus and WL Gore; holds a financial interest in AccessClosure, Augmenix, Boston Scientific*,Claret Medical Inc, Micrus and Valor Medical; has a board/trustee/officer position with AccessClosure, Claret Medical Inc and Micrus (until September 2010); belongs to the Abbott Vascular speakers' bureau; and receives honoraria from Bard, Boston Scientific*, Cordis, Memorial Healthcare System, Complete Conference Management, SCAI and Cleveland Clinic. EIL receives research grant support (principal investigator: Stent-Assisted Recanalization in acute Ischemic Stroke, SARIS), other research support (devices) and honoraria from Boston Scientific* and research support from Codman and Shurtleff Inc and ev3/Covidien Vascular Therapies; has ownership interests in Intratech Medical Ltd and Mynx/Access Closure; serves as a consultant on the board of Scientific Advisors to Codman and Shurtleff Inc; serves as a consultant per project and/or per hour for Codman and Shurtleff Inc, ev3/Covidien Vascular Therapies and TheraSyn Sensors, Inc; and receives fees for carotid stent training from Abbott Vascular and ev3/Covidien Vascular Therapies. EIL receives no consulting salary arrangements. All consulting is per project and/or per hour. (*Boston Scientific's neurovascular business has been acquired by Stryker.) AHS has received research grants from the National Institutes of Health (co-investigator: NINDS 1R01NS064592-01A1, Hemodynamic induction of pathologic remodeling leading to intracranial aneurysms; not related to present manuscript) and the University at Buffalo (Research Development Award); holds financial interests in Hotspur, Intratech Medical, StimSox and Valor Medical; serves as a consultant to Codman and Shurtleff Inc, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting and Penumbra; belongs to the speakers' bureaus of Codman and Shurtleff Inc and Genentech; serves on an advisory board for Codman and Shurtleff; and has received honoraria from Abbott Vascular, American Association of Neurological Surgeons' courses, an emergency medicine conference, Genentech, Neocure Group LLC, an Emergency Medicine Conference and from Abbott Vascular and Codman and Shurtleff Inc. for training other neurointerventionists in carotid stenting and for training physicians in endovascular stenting for aneurysms. AHS receives no consulting salary arrangements. All consulting is per project and/or per hour. KVS serves as a consultant to, a member of the speakers' bureau and has received honoraria from Toshiba. He serves as a member of the speakers' bureau for ev3 and The Stroke Group (consultants to the healthcare industry, Littleton CO) and has received honoraria from these entities.

Ethics approval Procedures were performed at Millard Fillmore Gates Circle Hospital (a University at Buffalo affiliate). The institutional review board at the University at Buffalo approved the study, and a standard Health Insurance Portability and Accountability Act (HIPAA) compliant protocol was followed.

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